Periop Med Flashcards
PERIOP MED (Psych/drugs) - Methamphetamines
[20B11] Discuss the perioperative implications for a patient known to use methamphetamine.
!! [24B01]
Outline the perioperative management of a methamphetamine
intoxicated 20‑year old who requires urgent surgery.
Drug effect on behavour =
Mimic - endogenous monoamines (sympathomimetic) –> excitation and euphoria
- CVS
- Sympathomimetic - Resp
- smoking +/- PHTN - Metabolic
- Hyperthermia
- Met acidosis
- rhabdo
- malnutition
Acute vs chronic use
Chronic
- withdrawal, dependence, comorbidities
Hx
- drug / duration
- comorbidities
Ex
- intox –> consent?
Ix
- viral
- ECG - long QT
consent?
aggression –> BZD?
** INTRAOP = BP and vol**
1. BP - labile -
2. Aim euvolaemia
Postop = WD and refer*
- monitor withdrawal - sleep/eat/depress
- psych / A&D
24B01
Minimum Criteria:
* Considers drug effects on behaviour
* Considers consent responsibilities
* Considers reasons for urgent surgery (i.e. going ahead whilst intoxicated)
* Mentions physiological effects of methamphetamine toxicity with some reference to how this influences intraoperative management
* Postoperative problems are anticipated
Poorly scoring answers frequently omitted discussing the consent process and postoperative
issues in these patients
BT_PO 1.5
MAKE UP
[-] Discuss the perioperative implications for a patient known to use CANNABIS (instead of methamphetamine.)
SAD - substance abused disorder
CNS-depressant
- EtOH
- BZD
- opioids
CNS-stim
- cocaine
- amphetamines
- ecstasy
- CBD
Aim
1. Prevent w/d effective analgesia
2. Sx Rx of affective/behavioural problems
Key
1. Acute (consent) vs chronic use (poor nutrition, comorbid)
2. Difficult IV access
3. PPE
4. Post op analgesia plan
Natural vs synthetic
Oral vs pulm
Low bioavail
Long t1/2
Low tox
CBD
PM10 2019: Medicinal cannabis for chronic pain
OHA p.337
PERIOP MED (Neuro) – Parkinson’s disease
[21A06] You will be anaesthetising a 63-year-old man with severe Parkinson’s disease who is booked for an inguinal hernia repair. Discuss the issues that are relevant to providing perioperative care for this patient. (also 15A10, 09A05)
RTB
rigidity/tremor/bradykinesia
AUTONOMIC/cog/emo
Pathophys
ACh (exc) and DA (inh) imbal in BG –> loss of DA–> unopp EXC –> tremor/rigid
Drugs
- Levodopa
- Carbidopa
- DA agonist
- MAO-Bi
- COMTi
- Anti-ACH
- NMDA antag
Features
1. Cog change
2. Autonomic instability
3. Aspiration risk
4. Meds
- continue Da drugs
- avoid anti-Da )
Post op - return to meds
PERIOP MED (Neuro) – Myasthenia gravis
[20B09] A patient with myasthenia gravis presents for emergency laparotomy for small bowel obstruction.
Discuss your perioperative management of this patient including your choice of anaesthesia. (also 14B09, 06A05, 03B03)
MG
IgG autoab + POST-syn nAChR at NMJ
ocular
bulbar - aspiration
prox limb
ATIA
Dr Podcast
(60.6%) Application of knowledge of the condition and its perioperative management in the emergency setting was required here and the majority of candidates achieved a satisfactory standard.
Airway management, recognition of the emergency, assessment of severity, stability and current treatment required discussion.
Specifics relating to the implications of choice of muscle relaxants and sedative medication with post- operative considerations required discussion as did the management of the patient’s anticholinesterase therapy.
Areas where some candidates fell short included inadequately classifying the condition including the significance of bulbar symptoms, the requirement for replacement anticholinesterase therapy in the perioperative period and omitting detail of an analgesic plan in this patient (major open abdominal surgery with likely poor respiratory mechanics).
PERIOP MED (Neuro) – Peri-operative stroke
[19B13] List the risk factors for perioperative stroke. (50%)
Discuss the measures you use to ̄ perioperative stroke in high-risk patients undergoing major orthopaedic surgery. (50%) (also 12A13)
RF
patient:
1. Age > 70yo
2. F
3. Comorbin
Intraop
1. Type (cardiac/CEA)
2. Urgency (emerg > elec)
3. GA>RA>LA
4. Duration
Post op
1. AMI/AF
2. Dehyd
3. Hypergly
Periop Mx to dec stroke
1. Pre op
-
PERIOP MED (Neuro) – Traumatic SC transection at C6 (acute)
[15A14] A 40-year-old requires a laparotomy ten days after an isolated traumatic spinal cord transection at C6.
1. Outline the key anaesthetic issues. (50%)
2. How would these influence your anaesthetic management? (50%)
Key
1. Unstable C-spine
2. Neurogenic shock
3. Acute laparotomy
Neurogenic
- loss ANS
- dec BP, dec HR, peri VD
PERIOP MED (Neuro) – Longstanding C5-6 quadriplegia
[13B15] A 25-year-old female with longstanding C5-6 quadriplegia requires ureteric stent insertion. Outline the implications for anaesthesia.
PERIOP MED (Neuro) - Epilepsy
[13A05] What are the perioperative concerns for the anaesthetist managing a patient with epilepsy?
Epilepsy - common 1%
Anti-epileptic
Anaes agent ~ seizures
- IV - avoid etom/ket
- VA - avoind enf
- Opioid - avoid peth/tram
- NMBA - avoid sux(K up)/laudanosine from atrac
- LA - re ceiling dose
CYP450
Carb/pheny - indu
Valp - inhibit
PERIOP MED (GI) – Liver
[10B03] A 45-year-old man with a longstanding history of alcoholism is booked for upper gastrointestinal endoscopy and banding of oesophageal varices following an episode of haematemesis.
(a) How is the severity of this patient’s liver disease assessed? (50%)
(b) How do these findings influence your evaluation of this patient’s perioperative risk? (50%)
Liver scoring
1. MELD
- BIC - bili/INR/Cr
2. CP
- A/B/P/E/C
Extra-hepatic sequelae
1. HRS
2. HPS
Type/urgency of procedure
Type of anaes require
Comorbid
PERIOP MED (Haem) – von Willebrand disease
[19A13] Outline your approach to the perioperative management of a patient who gives a strong family history of von Willebrand disease.
Types of vWD (ISTH)
Quant def: 1 and 3
Qual def: 2
Mx Responder vs non-responder
Rx - DDAVP (desmo)
*rel vWF
Mx options
Mx - diff types of vWD
Features
1. 2050 a.a. plasma glyco
2. 1% AD chr 12mut
3. mucosal bleed
Rx:
1+2a - DDAVP
2b+3 - vWF replacement
Cryo - IIIF(fibronectin, fibrinogen, vWF), FVIII, FXIII
*F8/vWF = Humate P
PERIOP MED (Haem) – Anaemia 1
[19A10] These are the blood results of a 65-year-old man scheduled for a revision total hip replacement.
- Interpret these results (30%)
- How would you manage this patient preoperatively? (70%)
DDx
Micro/Normo/Macro
1. Hb
2. MCV - M/N/M
- IDA
- Ferritin <30
- Non-IDA
- Ferritin > 100
Optimise
PERIOP MED (Haem) – Minimising blood loss and transfusion
[15B03] An adult patient is scheduled for a major operation during which significant blood loss is expected. Describe strategies you would consider perioperatively when planning to minimise blood loss and transfusion requirement.
Key strategies PBM
*1. Mx anaemia
*2. Min BL
*3. Imp tol to anaemia
PERIOP MED (Haem) - VTE
[15A12] In PAC, you are assessing a patient who is concerned about the risk of developing venous thromboembolism (VTE) perioperatively.
a) Outline the patient factors that increase the risk of VTE. (50%)
b) Describe measures that may reduce the risk of perioperative VTE (50%)
(83.4%) Candidates were expected to at least mention
- a) Previous history/family, obesity, cancer and oestrogen containing pills
- b) Measures would include minimising the preop, intraop and postoperative risks
Background
(also 08B05, 05A02)
RF = virchows triad
Stasis, hypercoag, endo dam
Mx
1. Preop
a. STRATIFY
- Intraop
a. GCS
b. IPC
c. Pharm - Postop
a. Mob early
PERIOP MED – Addison’s disease
[21B08] Discuss how a diagnosis of Addison’s disease would influence your perioperative management of a patient who requires an urgent laparotomy for bowel obstruction.
Addison dx
- hypoTension
- low cortisol (GC) and aldosterone (MC)
Effect (add crisis from stress)
1. BGL low
2. Na low
3. K High
4. Urea high
Mx
1. Fludrocort
2. Hydrocort (GC+MC)
Preop
- C - consult endocrine
Intraop
1. IAL for BP monitoring
2. Electrolytes - Na/K
3. Steroid cover
- Hydrocortisone
- Dex 6-8mg - good for 24h
x dex - no MC activity
Post op
1.
PERIOP MED (Endocrine) – T2DM
[19A03] a) List the causes of increased perioperative morbidity and mortality in surgical patients with type 2 diabetes mellitus. (30%)
b) Outline the principles of perioperative management of these patients. (70%)..
(also 17A05, 09B02, 06A03)
Key
1. HbA1c <8.5% (postop if > 9)
2. BSL perio op: 5-10mmol/L
Perio
Meds
1. OHA - WH DOS
2. SGLT-2 - WH 2/7 prior + DOS
- If Ket > 1 and pH < 7.3/ HCO3 < 15 –> ivf + ins/dex
Patients with type 2 diabetes mellitus (T2DM) face elevated perioperative risks due to metabolic and vascular complications. Effective management requires preoperative optimisation, vigilant glucose monitoring, and tailored medication strategies to mitigate these risks.
a) Causes of increased perioperative morbidity and mortality
1. Hyperglycaemia-related complications:
- Increased postoperative infections (surgical site, respiratory, urinary)[1][7]
- Acute kidney injury and metabolic acidosis[7][8]
- Delayed wound healing and higher reoperation rates[7][8]
-
Macrovascular disease:
- Myocardial infarction and cardiovascular instability[2][8]
- Peripheral vascular disease exacerbating ischemia[7]
-
Microvascular complications:
- Neuropathy increasing aspiration/pressure injury risks[2]
- Retinopathy and nephropathy complicating fluid management[4][8]
-
Metabolic instability:
- Hypoglycaemia from fasting/medication mismanagement[6]
- Diabetic ketoacidosis/hyperosmolar states in severe hyperglycaemia[2]
-
Stress response:
- Surgery-induced insulin resistance and hepatic glucose overproduction[2][9]
b) Perioperative management principles
1. Preoperative optimisation
- Glycaemic control:
- Target HbA1c 8.5% (69 mmol/mol)[3][6]
- Avoid fasting >6 hours for solids/2 hours for clear fluids[4][6]
-
Medication adjustments:
- Stop 48h pre-op: SGLT2 inhibitors (risk of euglycaemic DKA)[9]
- Stop 24h pre-op: Metformin (renal safety), GLP-1 agonists (delayed gastric emptying)[5][6]
- Continue: Basal insulin with dose reduction (e.g., 80% of usual if fasting)[5][6]
2. Intraoperative management
- Blood glucose targets: 5–10 mmol/L (90–180 mg/dL)[5][6]
- Monitoring: Hourly BSL checks using point-of-care testing[5][9]
- Insulin strategies:
- Minor surgery: Subcutaneous rapid-acting insulin corrections[5]
- Major surgery: IV insulin infusion (e.g., 0.5–2 U/hr) with 5% dextrose[5][6]
3. Postoperative care
- Monitoring: 1–2 hourly BSL until stable, then 4-hourly[5][6]
- Reinstate medications when eating normally:
- Restart metformin 48h post-contrast/after renal function confirmed[5]
- Transition IV insulin to subcutaneous regimen using 80% of pre-op basal + mealtime corrections[9]
- Complication prevention:
- Early mobilisation to reduce thrombosis risk[4]
- Aggressive infection surveillance[6][8]
4. Special considerations
- Emergency surgery: Prioritise fluid resuscitation + IV insulin to correct hyperglycaemia/ketosis[9]
- Day surgery: Schedule as first case; use glucose-potassium-insulin infusions if prolonged fasting[4][6]
Australian guidelines emphasise individualised care, with protocols from the Australian Diabetes Society (ADS) and ANZCA recommending multidisciplinary coordination to address both surgical outcomes and long-term diabetes control[6][9]. Key gaps in suboptimal responses include omitting specific BSL targets, inadequate medication transition plans, and underestimating fasting duration impacts.
Citations:
[1] https://www.diabetessociety.com.au/documents/PerioperativeDiabetesManagementGuidelinesFINALCleanJuly2012.pdf
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC8394235/
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC6455978/
[4] https://www.cpoc.org.uk/sites/cpoc/files/documents/2021-03/CPOC-Guideline%20for%20Perioperative%20Care%20for%20People%20with%20Diabetes%20Mellitus%20Undergoing%20Elective%20and%20Emergency%20Surgery.pdf
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC5692120/
[6] https://perioptalk.org/wp-content/uploads/2013/11/diabetes-guidelines-website.pdf
[7] https://pubmed.ncbi.nlm.nih.gov/23834046/
[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC9204286/
[9] https://www.diabetessociety.com.au/guideline/ads-anzca-perioperative-diabetes-and-hyperglycaemia-guidelines-adults-november-2022/
[10] https://www.tandfonline.com/doi/full/10.1080/17446651.2023.2272865
[11] https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2022.841256/full
[12] https://emedicine.medscape.com/article/284451-overview
[13] https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Diabetes-surgery-0518.pdf
[14] https://www.wjgnet.com/1948-9358/full/v12/i8/1255.htm
[15] https://medlineplus.gov/ency/patientinstructions/000702.htm
[16] https://diabetesjournals.org/spectrum/article/15/1/44/890/Management-of-Diabetes-Mellitus-in-Surgical
[17] https://jamanetwork.com/journals/jamasurgery/fullarticle/2793063
[18] https://academic.oup.com/bjaed/article/17/4/129/2629524
[19] https://asmbs.org/patients/surgery-for-diabetes/
[20] https://www.cpoc.org.uk/guidelines-and-resources/guidelines/guideline-diabetes
[21] https://www.diabetessociety.com.au/ads-anzca-perioperative-hyperglycaemia-guidelines-adults/
[22] https://www.ncbi.nlm.nih.gov/books/NBK540965/
[23] https://www.diabetessociety.com.au/wp-content/uploads/2023/03/ADS-ANZCA-Perioperative-Diabetes-and-Hyperglycaemia-Guidelines-Adults-November-2022-v2-Final.pdf
[24] https://pharmaceutical-journal.com/article/ld/perioperative-management-of-type-2-diabetes-mellitus
[25] https://www.diabetessociety.com.au/guideline/ads-peri-operative-diabetes-management-guidelines/
[26] https://libguides.anzca.edu.au/pomtrain/U3M10
[27] https://www.diabetesaustralia.com.au/health-professional-guidelines/
[28] https://anaesthetists.org/Home/Resources-publications/Guidelines/Peri-operative-management-of-the-surgical-patient-with-diabetes
[29] https://asa.org.au/wp-content/uploads/2024/10/ASA-FS1-Perioperative-Management-of-Patients-on-GLP-1-Receptor-Agonists-GLP-1-RAs.pdf
[30] https://pmc.ncbi.nlm.nih.gov/articles/PMC9131255/
[31] https://webstor.srmist.edu.in/web_assets/srm_mainsite/files/files/Surgical%20complications%20of%20Diabetes.pdf
[32] https://catag.org.au/wp-content/uploads/CATAG-Topic_Diabetes_Practice-Tool_F.pdf
[33] https://pmc.ncbi.nlm.nih.gov/articles/PMC10375498/
Answer from Perplexity: pplx.ai/share
PERIOP MED (Endocrine) – T2DM + autonomic neuropathy
[16B14] A 45-year-old male with long standing diabetes is scheduled to undergo elective laparoscopic cholecystectomy.
a) In the preanaesthesia assessment clinic, how would you assess this patient for the presence of diabetic autonomic neuropathy? (50%) b) Discuss the anaesthetic implications of his autonomic neuropathy. (50%) (also 11A15, 05B03)
AN
- DM, PD etc
Ax (AUTONOMIC NEUROPATHY)
CVS
* Hydrostatic hypotesnvie
GI
- Gastroparesis -
GU
- impotence
- retention
Thermoreg
- loss of sweating
b) Implications
*Impaired BRR + inability to inc HR –> fixed CO
Intraop
- IDC
- preload
- pre-emp vasopressor
- resp++ to laryngoscopy
- asp risk
Post op
- silent ischaemia
PERIOP MED (Endocrine) – T2DM + HTN
[13B01] A 68-year-old man is scheduled for total knee replacement next week.
He has hypertension, for which he is prescribed enalapril, and type 2 diabetes, for which he is prescribed metformin.
Justify your perioperative management of his medications.
- Periop Risk strat
- Maintain “normal”
- GL+RECOMM!!
- Risk/Ben calc
General
1. Withdrawal
2. Disease progress
3. Interaction with anaes
4.
Controlled?
Omit both DOS
Consider
1. Anxiolytic - avoid stress
2. Intraop HTN - clon/hydral
3. Intraop BGL - freq measure + insulin inf
4. Resume meds ASAP post op
PERIOP MED (Endocrine) - Carcinoid syndrome
[18B11] Discuss your perioperative management of a patient with carcinoid syndrome presenting for small bowel resection.
sx by NE tumour secreting VASOACTIVE subs
- triad - heart/diahhoea/flushing
PREMED Rx - octreotide
50mcg/hr IV 12hr preop
Intraop
- Prop/Remi
Conflicts:
- RSI vs titr ind
- RSI vs avoid sux
- deep anes vs CV dysfx
POSTOP:
ICU/HDU - vol/elec/bsl/HD
wean octreotide
PERIOP MED (Endocrine) - Thyroidectomy
[17B08] Discuss the preoperative assessment for a patient who presents for thyroidectomy.
Mass effect, potential AW problems, adj structures, endocrine issues
Mass effect
1. AW
2. SVC return
PERIOP MED (Endocrine) - Acromegaly
[14A13] A 53 year-old man with acromegaly presents for a transphenoidal resection of his pituitary tumour.
a) Outline the features of acromegaly. (50%)
b) How does this diagnosis influence your anaesthetic management? (50%) (also 08A12)
Acro features
Heart + AW
DM/HTN/LVH/OSA
DHLO 30405060%
Dx:
1. Inc IGF-1
2. GH supp test
Rx:
1. Sx - pit macroadenoma
2. Adj. SOMATOSTATIN analogue
3. GH-r ANTAG (pegvisomat) (nonresp)
4. Pit irradiation
Pre:
1. AW ax
2. visual ax
3. OSA
4. CVS
Intraop
1. Secure DA
2. Crisis
a) post op stridor
b) endo emerg: DI, SIADH
3. Difficult access + IAL
- positioning
- HTN
- VAE
Postop
1. HDU/ICU
2. Upper CN signs
3. Hormonal supp - ?hydrocort
4. CSF leak, DI
PERIOP MED (Autoimmune, congenital, acquired) – Rheumatoid arthritis
[20A15] Discuss the anaesthetic considerations for an adult patient with rheumatoid arthritis presenting for wrist surgery. (also 02A10)
Key
1. RA severity
2. CVS/Resp involv
3. Meds
4. AA instab/AW consideration
5. Regional
6. Positioning
7. Analgesia
*DO NOT overcall
RA
- auto-infla
- symmetrical polyarthritis
- extra art involv
CR involvement
Current meds - DMARDS
steroids - >10mg = cover
MTX - ILD, hep fail
SSZ - neutro/thrombopaenia, IPF
AZA - hepatitis, BM supr
XR - ANT arch of atlas TO odontoid process > 3mm = AAS ***
Ix
1. TTE if sig SOB at rest
2. ABG if SpO2 < 95% RA or O2 Rx
3. Resp Ex + –> PFT + CXR
Intraop
1. RA > GA
2. Prep for DA, min C spine manip
3. Positioning
Post op
1. suitable for day surg
2. HDU/ICU if concerns
3. restart reg meds ASAP
4. multi modal
5. OT - hand fx important
PERIOP MED (Autoimmune, congenital, acquired) – Marfan Syndrome
[19B03] Discuss how Marfan syndrome influences your anaesthetic management for a patient requiring an urgent laparoscopic appendicectomy.
Key
1. CVS ~ BP control - laryngoscopy, pneumo and ext
2. AW issues
3. Lung path - avoid PTX 2o bullae
Marfan
- AD CT metab
- fibrillin 1 gene on chr 15
- ## stiff aortic walls
DASI and METS
VO2 peak (mL/kg) = 0.43 × DASI + 9.6
DASI 34 –> 24
METs (metabolic equivalents) = VO2 peak / 3.5
PERIOP MED (Autoimmune, congenital, acquired) - Frailty
[19A11] Define frailty and discuss the role of prehabilitation for patients with frailty.
Frailty
- multidimensional
- depletion of physiological reserve
- vulnerable to stress
- harder to recover from illness
- independent RF for higher M&M
- “CLINICAL FRAILTY SCALE”
Prehab
- enhancing fx cap
- withstand stressor
- improve baseline + shorten recovery
4 approach
1. Med optimise
2. Phys exercise
3. Nutritional support
4. Psych support
Benefits (theoretical)
- improbve CR fx
- dec LOS, post op pain, post op comp
Limitations
1. limited evidence
2. variation/no std protoc
3. Cost
4. Var compliance
Prehabilitation
https://academic.oup.com/bjaed/article/17/12/401/4083340
